Presented by Josh King and Stephanie Dowd

1. The Efficacy of Play Therapywith Children:A Meta-Analytic Review of Treatment OutcomesSue C. Bratton, Ph.D., Dee Ray, Ph.D., Tammy Rhine, Ph.D., and Leslie Jones, Ph.D.Professional Psychology: Research and Practice (2005), Vol. 36, No. 4, 376-390 Presented by Josh King and Stephanie Dowd

2. Need for Identifying Effective Treatments Based on the most recent U.S. Surgeon General’s Report (U.S. Public Health Service, 2000): • Mental illness is the leading cause of disability for all persons 5 years of age and older. • The shortage of appropriate mental health services for children is a major health crisis. • Although 1 in 10 of all children suffer from emotional and behavioral problems severe enough to impair normal functioning, less than half receive treatment. • Therefore, identifying effective interventions for children and their families is critical.

3. Why Play Therapy for Children? • Play therapy is responsive to children’s unique and varied developmental needs. • Most children below age 11 lack a fully developed capacity for abstract thought (Piaget). • Children have not yet developed the capacity for meaningful verbal expression and understanding of complex issues, motives, and feelings. • Unlike adults who communicate naturally through words, children more naturally express themselves through the concrete world of play.

4. What is Play Therapy? • Play therapy is the vehicle for communication between a child and a therapist. • It is based on the assumption that children will use play materials to directly or symbolically act out feelings, thoughts, and experiences that they are unable to express meaningfully in words.

5. History of Play Therapy • Anna Freud (1928) and Melanie Klein (1932) are known as the founders of play therapy. • Play was used as a substitute for verbal free association as an attempt to apply their analytic techniques to work with children. • Virginia Axline’s (1947) work viewed play as a child’s natural mode of expression and trusted the child to have the capacity to resolve their conflicts through play. • Her work and research was instrumental in broadening acceptance for play therapy as a psychotherapeutic treatment for children.

6. Filial Therapy • In the early 1960s, Bernard and Louise Guerney recognized a shortage of mental health professionals so they developed a model for training and supervising parents in client-centered play therapy methods to use with their own children. • This is called Filial Therapy. • It has also been developed to train teachers, mentors, and other paraprofessionals who work with children.

7. Multiple Specific Play Therapy Approaches • Gestalt Play Therapy (Oaklander, 1994) • Adlerian Play Therapy (Kottman, 1995) • Ecosystemic Play Therapy (O’Conner, 2000) • Prescriptive Play Therapy (Schaefer, 2001)

8. Play Therapy Today • Even though play therapy has been used by child therapists since the early 1900s, it was not established as a specialized treatment modality within the mental health field until 1982 (by the Association for Play Therapy, APT). • With the development of university-based play therapy training programs and over 2,200 play therapy publications it has rapidly grown and developed over the last 20 years. • Today, play therapy is widely used.

9. Play Therapy Criticized • Despite the wide-spread use of play therapy, it has not received acceptance as an effective treatment modality by the scientific community. • It has often been criticized for lack of sound empirical evidence to support its use.

10. Play Therapy Research Criticism • The authors’ review of play therapy literature revealed only a small number of well-designed studies that yielded statistically significant results. • There was a greater number of studies with flawed or insufficient research design. • Many studies were hindered due to small sample sizes and therefore, an inability to generalize results.

11. Next Step • Scientifically proving the effectiveness of any therapeutic intervention is essential to its widespread acceptance as a viable treatment.

12. Measure of Treatment Effect A Statistical Review

13. What is Effect Size • A standard measure of change in the treatment group compared to the control group. • me is the experimental post-therapy group mean. • mc is the control group mean. • sp is the pooled standard deviation.

14. Effect Size Interpretation • Effect size is measured in Standard Deviations • E.g. An effect size of 0.71 means that the experimental group performed 0.71 standard deviations better than the control group. • 0.20 = Small effect0.50 = Medium effect0.80 = Large effect(Cohen, 1988)

15. Meta-Analytic Methodology • Meta-analyses allow the researcher to overcome small sample sizes by combining results to produce an understanding of its overall treatment efficacy.

16. Previous Meta-Analyses on Child Therapy • Casey & Berman (1985) published the first meta-analyses of child therapy outcome studies. • They looked at 75 controlled studies published from 1952 to 1983 and found a mean treatment effect of 0.71 standard deviations. In other words, the average treated child performed better after treatment than 76% of the control children. • They found no significant difference between play-based and non-play interventions.

17. Previous Meta-Analyses on Child Therapy • Four additional meta-analyses looked at child therapy outcome data ranging from the 1950s through the 1990s. • Weisz et al. (1987, 1995) provided largest body of research to date and found that behavioral interventions show to be superior over non-behavioral child therapy interventions. • Caveat: Weisz et al. largely ignored play therapy studies in their meta-analyses.

18. Previous Meta-Analyses on Child Therapy • LeBlanc and Ritchie (2001) provided the most recent meta-analyses that focuses exclusively on the efficacy of play therapy. • Their findings show an average treatment effect of 0.66 standard deviations. • Additionally, they found a strong relationship between treatment effect and A.) The inclusion of parents in a child’s therapy B.) Treatment duration

19. Present Meta-Analytic Review • The present study was designed to expand on LeBlanc and Ritchie’s findings by more than doubling the number of play therapy studies reviewed (n = 93). • Additionally, its purpose was to contribute to the field’s understanding of the variables related to psychotherapy effectiveness.

20. Selection of Studies • They wanted to avoid “publication bias”: studies lacking statistically significant findings, with small sample sizes and insufficient power are rejected from being published. • Bratton et al. exhausted all resources, i.e. both published and unpublished play therapy outcome studies. • Including Dissertation Abstracts, online Psych search engines, 10 major play therapy journals, etc.

21. Specific Study Criteria • Studies were screened for: • Use of controlled research design • Sufficient data for computing effect size • Use of play therapy intervention as operationally defined by present authors

22. Operational Definition of Play Therapy • Per the Association for Play Therapy (2001): “The systematic use of a theoretical model to establish an interpersonal process wherein trained play therapists use the therapeutic powers of play to help clients prevent or resolve psychosocial difficulties and achieve optimal growth and development.”

23. Final Selection • Spanning 1953 – 2000, 93 articles met study criteria. • 41 refereed journal articles, 2 ERIC documents, and 50 unpublished dissertation • Each study in this meta-analysis: • used a control or comparison group design. • used pre- and/or post- measures. • reported sufficient statistical data to calculate treatment effect.

24. Study Variables • The Study Variables that were analyzed: • Treatment modality/theoretical model used • Treatment provider: mental health professional vs. trained paraprofessionals (primarily parents) supervised by a professional • Treatment setting • Treatment duration • Treatment format (group vs. individual) • Presenting issues/target problem behavior • Type, number, and source of outcome measures • Gender, age, and ethnicity of child participants • Published vs. unpublished document • Study design • Source of child participants (clinical vs. analog) • Interrater reliability was established (r = 0.9719).

25. Results • Overall, the mean effect size was 0.80 + 0.04 (p < .001), revealing a large treatment effect for play therapy interventions. • In other words, children receiving play therapy performed more than ¾ of a standard deviation better on given outcome measures as compared to children who did not receive play therapy.

26. Results • The present meta-analysis is consistent with, or higher, than previous meta-analyses that looked at all forms of child therapy (effect size ranging 0.65 – 0.84).

27. Results • The meta-analytic reviews that focused completely on play therapy revealed effect sizes of 0.65 (n=20) and 0.66 (n=42). • Bratton et al. spanned the same decades, a more comprehensive review by using a larger sample size (n=93), and found a effect size of 0.80.

28. Implication of Unpublished Studies • Most meta-analyses are criticized for over-reliance on published data. • The earlier child meta-analytic researchers only looked at published studies. • The current study avoided “publication bias” by including unpublished studies, some of which may not have had statistically significant findings. • The fact that the current study still found a large treatment effect, in spite of the inclusion of unpublished studies, speaks to the strength of their findings and the efficacy of play therapy.

29. Play Therapy Variables • Treatment Type: • Humanistic-Nondirective vs. Nonhumanistic-Directive • Treatment Provider: • Psychologist vs. Paraprofessional vs. Parent • Treatment Setting: • School vs. Outpatient Clinic vs. Residential vs. Critical Incident • Treatment Format: • Group Therapy (Professional) vs. Individual Therapy (Professional) vs. Individual Therapy (Paraprofessional)

30. Outcome – Treatment Type • Both considered Effective • Interpret carefully: small N for Nonhumanistic-Directive. • There is little evidence that one approach is better than another approach.

31. Outcome – Treatment Provider • Surgeon General’s Conference on Children’s Mental Health, 2000 • Recommends family engagement in intervention strategies. • Parents who are willing to be involved in their child’s therapy are likely different from parents who want no part in their child’s therapy. • Professionals may have been assigned more difficult cases than were Parents or Paraprofessionals.

32. Outcome – Treatment Setting • Interpret carefully: small N’s. • Mean number of sessions for clinic setting was nearly 3 times more than in schools (22.4 to 8.4). • Children in the critical incident category showed an inverse relation between ES and number of sessions.

33. Outcome – Treatment Format • Several other studies report no significant difference between group and individual therapy (by a professional). • Consistent with previous results on involving parents in children’s play.

34. Outcomes - Other • Duration • Optimal effects were 35 – 40 sessions. • Many studies with smaller than 14 sessions also had medium to large ES’s. • The mean number of sessions was 16.9. • Children not getting the optimal number of sessions. • Age & Gender • Neither were significant predictors of treatment outcome. • The data on this was not very complete.

35. Outcomes - Other • Target Behavior Problems • No significant difference between Internalizing, Externalizing, both together, and “Other” problem behaviors.

36. Summary and Limitations • Play therapy is a viable intervention. • Treatment variables and treatment outcome have unclear findings. • Limitations: • “Meta-analyses are only as strong as the individual studies that are submitted to the statistical procedures.” • Many studies were excluded because they were not statistically acceptable. • Missing factors: • Training level of therapist; age, gender, and/or ethnicity of patient; ill-defined presenting problems; etc.

37. Conclusion and Implications for Practice • Many question the validity of play therapy. • This study serves to debunk the stigma that play therapy is “just playing”.

38. Conclusions and Implications for Practice • Some factors appear to be more predictive of better treatment outcomes than others. 1. Humanistic-Nondirective play (n=73) produces larger treatment effects than Nonhumanistic-Directive play (n=12).* • This is inconsistent with overall findings on adult psychotherapy where various types of therapy are shown to have equal effect. *Interpret cautiously due to large variance in n.

39. Conclusions and Implications for Practice • Some factors appear to be more predictive of better treatment outcomes than others. 2. Length of Treatment • Efficacy of play therapy by a therapist increases with number of sessions (approx. 35 sessions.) • Managed Care Barriers

40. Conclusions and Implications for Practice • Some factors appear to be more predictive of better treatment outcomes than others. 3. Parent Involvement • Simply working with the parents is not enough. • Involving the parents fully in therapy, along with providing structured, supervised experiences for parents to practice their skills is the most effective.

41. Conclusions and Implications for Practice • Some factors appear to be more predictive of better treatment outcomes than others. 4. Filial Therapy Training Protocol • Guerney Model (prior to 1980s) • Landreth Model (1990-2000) • These findings point to the benefit of filial therapy and adherence to a well-developed protocol.

42. Conclusions and Implications for Practice • Parents vs. Therapist • Overall, play therapy delivered by therapist shows a medium to large effect size whereas filial therapy produces a larger effect size. • Clinical rationale would prohibit use of filial therapy with all parents and children. • Parents experiencing significant amount of stress • Parents who are unwilling to participate • Child with significant emotional issues that extend beyond scope of parent • Humbling Result = If a child and a parent are both willing and able, filial therapy is the most effective therapeutic intervention.

43. Areas of Future Research • Future play therapy research should learn from limitations in previous studies: • Increase number of participants to increase ability to generalize to larger population. • Calculate and report effect sizes to address concern of small sample sizes. • Report the training of therapists and protocols utilized in treatment.

44. Areas of Future Research • Most play therapy research uses designs that compare play therapy to absence of intervention. • Therefore, they are unable to declare that play therapy is the most effective intervention. • A well-designed research methodology that compares its effectiveness directly with other child psychotherapeutic treatments, such as traditional behavioral plans, cognitive therapy, school guidance curricula, etc. is needed.